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      Anonymous
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      Tuberculosis in India
      (Published 23 March 2015)
      BMJ 2015;350:h1080

      Zarir F Udwadia, consultant physician, P D Hinduja National Hospital and Medical Research Centre, Mumbai, India, Chapal Mehra, public health specialist, New Delhi, India

      An ancient enemy just gets stronger

      Twenty years ago it was widely believed that India was successfully on its way to controlling its alarming tuberculosis (TB) epidemic. The country’s massive scale-up and implementation of directly observed treatment short course (DOTS) therapy under the Revised National Tuberculosis Control Program (RNTCP) was lauded internationally as a global model of excellence.

      Yet this represented only half of the story of TB in India. A terrifying picture of the death, devastation, poverty, and suffering caused by TB began to emerge almost two decades later, when it became apparent that TB in India was not just a national crisis but a global one.
      Each year India has 2.2 million new cases, more than 300?000 deaths, and economic losses of $23bn (£14.9bn; €20.3bn) from TB,1 making it India’s biggest health crisis.

      At the heart of this crisis is the failure of India’s RNTCP to engage and monitor the country’s large and unregulated private sector.
      This is where most patients with TB seek initial care despite extensive evidence of inaccurate diagnostics and inappropriate treatment.
      Patients with TB in India typically flit between an unsympathetic public sector and an exploitative private sector, until they are too sick or impoverished to do so, all the while continuing to transmit and spread tuberculosis in crowded home and work environments.

      TB was finally made a notifiable disease only in May 2012!!

      India needs to do much more if it seriously wants to control its TB epidemic. This will require immediate and massive investment in public health infrastructure, particularly new diagnostics and treatment. It also needs to tackle the long neglected social determinants of TB.

      Most patients with TB still lack access to stable employment, nutrition, decent housing, and high quality healthcare. The dysfunctional relationship between the private and public sectors also needs urgent attention.

      India must work at providing every TB patient with free and accurate diagnosis and the right treatment, whether in the public or the private sector. When TB is diagnosed, patients and their families must receive counselling, nutrition,and economic support. The programme must treat all patients who have TB, irrespective of their resistance pattern.
      And India desperately needs new drugs for the growing population of patients with more extreme forms of drug resistant TB, who have nearly exhausted the available first and second line drugs.

      A group of experts recently put together recommendations for India’s prime minister, urging him to tackle TB as a national emergency.

      In particular, these experts focused on issues of public awareness, diagnosis, treatment, drug resistance, nutritional support, and private sector engagement.

      This was a reminder that effective TB control needs more than new strategies: it needs political will and commitment, backed by sufficient resources. Unless this happens, TB will continue to be India’s silent epidemic and a death sentence for poor people.

      G Mohan.

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